Editorial: Is decision analysis useful in clinical medicine?
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Biomedical subjects
Publications and source records attributed to A R Feinstein.
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In children and adolescents who each had at least one previous episode of rheumatic fever and who were not maintaining effective anti-streptococcal prophylaxis, the attack rates of subsequent streptococcal infections declined with advancing age, but were unaffected by gender, cardiac status, or multiplicity of antecedent rheumatic episodes. The rate of rheumatic recurrence per streptococcal infection fell with advancing age, but rose with increasing amounts of cardiac damage and with multiplicity of previous rheumatic attacks. The results suggest that the underlying clinical features of the host have a greater effect on the rheumatogenicity of an acquired streptococcal infection than on the ability to avoid the infection.
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Existing systems of staging for patients with rectal cancer depend almost exclusively on anatomic evidence. Consequently, the stages cannot be determined in advance of therapeutic decisions and cannot be used for patients treated without surgery. Furthermore, the stages contain no provision for important prognostic distinctions, that cannot be discerned from anatomic data. After preparing a taxonomy for hiterto unclassified medical data, we developed and tested two new systems of staging in a cohort if 318 patients. The first system which can be applied before treatment, is divided into four composite stages that contain elements of symptomatic, chronometric, co-morbid, and para-morbid data, as well as information obtained from physical examination, sigmoidoscopy, and roentgenography. The second system, applicable to patients with resected tumors, is based on a combination of pre-therapeutic clinical information and post-surgical anatomic evidence. The two systems produce prognostic gradients that are clinically distinctive and statistically efficacious.
Two new biologically composite systems of staging were used to analyze the patterns of presentation, therapy, and outcome for 318 patients with rectal cancer. Selectional bias was evident in therapeutic decisions. The patients chosen for surgical exploration and possible resection came mainly from prognostically favorable stages and had higher survival rates than the "inoperable" patients wven when the tumor was not resected. In patients with tumors located 8 cm or higher above the anus, survival rates in each composite symptom-anatomic (S-A) stage were essentially similar with radical and simple resections. Radical surgery gave better survival rates than simple surgery for tumors at 5 to 7 cm and was an anatomic necessity to remove tumors at 0 to 4 cm. Regardless of the extensiveness of surgery, the S-A stages were directly related to rates of postoperative infection, postoperative death, subsequent quality of life, and deaths due either to cancer or to noncancer causes.
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